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© 2003 SAGE Publications Designing Clinically Useful Systems: Examples from Medicine and DentistryPresented at "Dental Informatics & Dental Research: Making the Connection", a conference held in, Bethesda, MD, USA, June 12–13, 2003, sponsored by the University of Pittsburgh Center for Dental Informatics and supported in part by award 1R13DE014611-01 from the National Institute of Dental and Craniofacial Research/National Library of Medicine.
Department of Medical Sciences, Medical Informatics and Engineering, Uppsala University, University Hospital, 82:1, SE-751 85 Uppsala, Sweden; sabine.koch{at}medsci.uu.se
Despite promising results in medical informatics research and the development of a large number of different systems, few systems get beyond a prototype state and are really used in practice. Among other factors, the lack of explicit user focus is one main reason. The research projects presented in this paper follow a user-centered system development approach based on extensive work analyses in interdisciplinary working groups, taking into account human cognitive performance. Different medical and health-care specialists, together with researchers in human-computer interaction and medical informatics, specify future clinical work scenarios. Special focus is put on analysis and design of the information and communication flow and on exploration of intuitive visualization and interaction techniques for clinical information. Adequate choice of the technical access device is made depending on the user’s work situation. It is the purpose of this paper to apply this method in two different research projects and thereby to show its potential for designing clinically useful systems that do support and not hamper clinical work. These research projects cover IT support for chairside work in dentistry (http://www.dis.uu.se/mdi/research/projects/orquest) and ICT support for home health care of elderly citizens (http://www.medsci.uu.se/mie/project/closecare).
Key Words: Dental informatics • home health care • human-computer interaction • medical informatics
Research in medical and dental informatics has resulted in the development of a large number of demonstrators, prototypes, and/or systems. However, many of these research results did not reach clinical practice, since they either never overcame a prototype state or could be used only in restricted settings by a few clinicians. Especially with regard to clinical decision support, there is a general consensus that various systems are little used, even though their potential benefits have been demonstrated repeatedly (Kaplan, 2001). Reasons for the insufficient use in clinical practice may be many: IT systems available in health care today have very rarely taken the end user’s needs into account when developed, but have traditionally been the tools of administrators rather than clinicians. Furthermore, many development projects have been technology-driven instead of focusing on actual user needs, the working environment, and the work process. As a result, a great many isolated systems that are unable to communicate and share information have been developed. In addition, existing projects quite often lack a thorough evaluation of organizational, economic, and health-quality effects, leading to an insufficient base for decision-making during system acquisition. As a consequence, decisions on purchasing a system are, due to economic restrictions, based mainly on possible integration with existing systems, hampering the "come through" of new innovative systems. Better interconnectivity and integration between and among different systems based on open standards and interfaces are on the way. Nevertheless, insufficient user focus, insufficient work process integration, and the lack of user-centered system development still inhibit user acceptance. The lack of good human-computer interfaces, for example, has been identified as a major impediment to the acceptance and routine use of many types of computing systems in health care (Patel and Kushniruk, 1997). For clinically relevant project results to be achieved, formation of interdisciplinary project teams with experienced professionals from different fields is mandatory. This includes health professionals from different disciplines, medical informaticians, human-computer interaction specialists, and professionals from related domains of interest (e.g., perception psychologists). About 10 years ago, Schneider described the unique chance for dental informatics to learn and profit from the experiences and mistakes made in medical informatics. He claimed motivation and engagement of experienced researchers, educators, and health professionals from various disciplines forming real interdisciplinary project teams to be the key to success (Schneider, 1992). Based on Schneider’s experiences, a method for user-centered system development using a work-scenario-oriented approach is further explored in this paper. It is the purpose of this paper to apply this method in two different research projects and thereby to show its potential for designing clinically useful systems that support and not hamper clinical work.
Health-care professionals have their primary focus on the quality of the care they provide for their patients. Therefore, any health information system developed must be as intuitive and user-friendly as possible to support and not hamper clinical work processes. Usage of existing and modified methods and techniques from the Human-Computer Interaction (HCI) domain—as described, for example, by Nielsen (1994)—are therefore of great value.
The proposed method is based on a general user-centered system development approach (ISO, 1999) and takes both actual user needs and the working environment into account. Interdisciplinary working groups are formed and persist during the entire system development process (Fig. 1
Human cognitive processes can be described to take place on two levels, an upper, conscious level and a lower, unconscious level. On the upper level, advanced processes such as decision-making can be performed. However, its capacity with regard to information processing and short-term memory is limited. On the lower level, which is controlled by the upper level, an almost unlimited amount of processes can be ongoing in parallel. Obviously, all information should be presented so that it can easily be grasped and managed by processes of the lower level, not overloading the limited capacity of the upper level. Clearly, optimal clinical work conditions require optimization of the graphic user interface to avoid cognitive information overload and to attain good usability. With this approach, prototypes are iteratively developed, tested, and refined in the working groups at first, and later evaluated at a larger number of different test sites to prove system scalability.
The proposed method has been applied in different research projects so that clinically useful systems could be developed. Two examples are presented in this paper. The first one consists of a project developing IT support for chairside clinical work in dentistry. This project has left its prototype state and is being commercialized and in use today for both clinical work and education. The second project, which is currently ongoing, deals with home health care of elderly citizens. A first test version has recently been implemented.
From research prototype to product: chairside support in dentistry
It is well-known that the basis of appropriate clinical management is the continuous holistic understanding of a clinical situation. This requires that, at chairside, all clinical information can be immediately accessed, easily managed, and quickly grasped and understood "in one view". "All clinical information" means dental records including medical and dental history, oral status (charting), treatment plan and progress notes, radiographs, and risk factors (Fig. 2
Fully integrated into the dental treatment unit, the workstation includes a voice-activated, electronic clinical patient record developed by I.-V. Wagner and W. Schneider (Wagner, 1992; (Schneider and Wagner, 1993; Wagner and Schneider, 1998), support with regard to assessment and improvement of the technical quality of radiographs (Koch et al., 1998a, 2000), and image- and rule-based decision support for interpretation of radiographs and for diagnosis and treatment of oral mucosal lesions (Wagner and Schneider, 1991; Schneider and Wagner, 1993). In addition, video-conferencing, including application-sharing facilities for expert consultation, and improved dentist-dental technician communication and interactive programs for patient education and retrospective evaluation are provided. Hardware integration into the dental unit is done in an ergonomically optimal way, with a movable flat screen, providing different input modes and allowing for direct access to digital radiography and an intra-oral camera (Fig. 3  ).
The ORQUEST interdisciplinary project team consisted of general dental practitioners (GDPs), different dental specialists (such as prosthodontists, implantologists, and periodontologists), medical informaticians, specialists in human-computer interaction, and system programmers. The prototype developed within the ORQUEST project has been clinically evaluated at 12 different European test sites, including GDPs, specialist clinics, and hospitals. After clinical evaluation, parts of the prototype have been commercialized and are in routine use today at the Catholic University of Portugal at Viseu under the leadership of Prof. Ina-Veronika Wagner for both clinical work and education.
Usage of clinical products for integrated education At the Catholic University of Portugal at Viseu, dental students use parts of the ORQUEST prototype, which were commercialized by Planmeca Oy (Finland), as educational tools for integrated, problem-oriented education with real clinical cases. Furthermore, a European Consortium for Post-Graduate Education in Applied Informatics in Dentistry has been established to educate dentists, teachers from dental schools, dental technicians, hygienists, nurses, employees of dental and insurance companies, and others involved in dentistry with regard to the appropriate use of information technology in dentistry. The Consortium, formed by a group of Dental Schools and other organizations, delivers a wide range of modules on different aspects of applied informatics relevant to dentistry, leading to the award of a European Diploma or Master’s Degree (http://siso.crb.ucp.pt/ediploma).
Academia, public sector, and industry in cooperation: home health care for the elderly
Home care of the elderly today is performed by different types of care providers: medical personnel such as general practitioners or district nurses, and community service personnel in charge of non-medical services, e.g., the patient’s daily hygiene. Even though these care providers, especially the home help service, have a mobile work situation, they very rarely have any mobile IT tools supporting their work. Usually, they either document their respective patient record system at the office or on paper. In addition, different users document in different, often incompatible, base systems. The lack of adequate mobile information access and communication tools clearly hampers the different care providers when it comes to documenting and communicating patient-oriented data. Furthermore, in many countries, e.g., in Sweden, home care of the elderly is shared among different health-care provider organizations. Therefore, a thorough user needs and work analysis, describing the entire work process and the different information and communication flows, is necessary. The results of the user needs analysis in this project specify exactly which information is needed for the different users in specified work situations. The information needed mainly consists of patient-oriented data stored in different health record systems (= base systems) that each care provider maintains for the respective patient. Mobile access to both data of the primary and other care providers’ base systems is mandatory. Different categories of care providers need different views on the entire set of data depending on their work situation. For relevant, context-dependent data to be appropriately filtered, the amount of information stored in the base systems is reduced and ranked in order of priority with respect to user category and work situation. As a result, access will be given to prioritized information in adequate format (PIF) through a virtual health record with different data views for the different user categories (Fig. 4
Within this project, a thorough work and user needs analysis has been performed in interdisciplinary working groups, allowing for a holistic view of the entire work process. The project has completed the specification and design phases. The first prototypes have recently been implemented and will be tested and further developed iteratively. So that the project results can be successfullly converted into clinical practice, the project is organized according to the Triple-Helix model (Etzkowitz and Leydesdorff, 1997), based on a unique network of partners from academia, the public sector, and industry. Evaluation of the project results will include usability testing and evaluation and analysis of life and work satisfaction and changed quality of life for health-care providers, patients, and relatives.
The author believes that user-centered system development in interdisciplinary working groups, taking into account human-cognitive performance, allows for a holistic view of the entire work/care process and thereby enhances user acceptance and provides health information systems that are accepted and used in clinical practice. Detailed design and analysis of the information and communication flow in different work situations, in combination with intuitive visualization and interaction techniques, lead to the development of systems that support clinical work processes for different categories of care providers. In addition, system development in interdisciplinary working groups results in a better mutual understanding of different working environments and conditions and the exchange of knowledge and experiences between and among different user groups and users and developers. Furthermore, a continuous educational effect and better understanding of the possibilities and restrictions of information technology for the respective clinical field is provided. This is especially true for user groups that include several health-care professions and for user groups with little experience when it comes to IT and insufficient consciousness of the entire work process.
The ORQUEST project has been partly supported by the European Commission, DG XIII, Telematics Application Programme-Health Care, Project No. 1037. Project coordinator, Ina-Veronika Wagner (CMD, Uppsala); technical project management, Werner Schneider and Sabine Koch (CMD, Uppsala). The electronic dental patient record has been developed by Ina-Veronika Wagner and Werner Schneider (CMD, Uppsala) and is now distributed by Planmeca Oy. The decision support system for oral radiology has been developed by Ina-Veronika Wagner and Werner Schneider (CMD, Uppsala), together with Stuart White (UCLA, Los Angeles) and Paul van der Stelt (ACTA, Amsterdam), and is now distributed by Quintessence Publishing Company. The decision support system for oral mucosal lesions has been developed by Manfred Straßburg (University of Düsseldorf), Ina-Veronika Wagner, and Werner Schneider (CMD, Uppsala) and is now distributed by Quintessence Publishing Company. The project "Technical support for Mobile CloseCare" is supported by VINNOVA—Swedish Agency for Innovation Systems (P23037-1 A) and Trygghetsfonden, as well as by the following clinical and industrial partners: Primary Care Hälsingland, County Council of Gävleborg, Municipality of Hudiksvall, DataVis AB, Ericsson Network Technologies AB, Bergsjö Data AB, and AB Hudiksvallsbostäder. Project leader, Sabine Koch (Department of Medical Sciences, Uppsala).
Publication supported by Software of Excellence (Auckland, NZ)
Advances in Dental Research, Vol. 17, No. 1,
65-68 (2003)
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Abstract
Introduction
